Millcreek Manor
Open-data reference.
Millcreek Manor is a non profit - corporation facility in ERIE, PA with 144 certified beds and a 4-star overall CMS rating. The facility has 32 deficiency records on file. Total penalties: $100K.
5535 PEACH STREET, ERIE, PA 16509
Phone: 8148687395
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 396072
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 144
- Residents
- 137
- In Hospital
- No
- County
- Erie
- Last Inspection
- Jan 23, 2026
Staffing Data
- RN Hours
- 0.96 (nat'l avg: 0.68)
- LPN Hours
- 0.91
- CNA Hours
- 2.37
- Total Nursing Hours
- 4.24 (nat'l avg: 3.89)
- PT Hours
- 0.10
- Nursing Turnover
- 45.1%
- RN Turnover
- 33.3%
What the CMS Record Reveals About Millcreek Manor
Millcreek Manor operates 144 certified beds in ERIE, PA with approximately 137 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (5★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 32 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $100K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.24 total nursing hours per resident day (national average 3.89), with RN coverage at 0.96 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Millcreek Manor falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 45.1%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (32 most recent)
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Jan 5, 2026
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 25, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 25, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Apr 22, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Category: Pharmacy Service Deficiencies
Corrected: Feb 21, 2025
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Category: Pharmacy Service Deficiencies
Corrected: Feb 21, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Feb 21, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Oct 7, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 16, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 1, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Apr 1, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Category: Pharmacy Service Deficiencies
Corrected: Apr 1, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 1, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 1, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 1, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 1, 2024
Assess the resident when there is a significant change in condition
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 1, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Apr 1, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 4, 2024
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Mar 4, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 4, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 17, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 17, 2023
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Category: Resident Rights Deficiencies
Corrected: Nov 17, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Nov 17, 2023
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category: Administration Deficiencies
Corrected: May 14, 2023
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Category: Pharmacy Service Deficiencies
Corrected: May 14, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: May 14, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: May 14, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 14, 2023
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Category: Resident Rights Deficiencies
Corrected: May 14, 2023
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Mar 18, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.2% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 9.4% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 8.2% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 62.9% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 38.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 7.9% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 19.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 51.1% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 39.5% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.6% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 29.9% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 12.8% | Yes |
Penalty History 1 penalties totaling $100K
| Date | Type | Amount |
|---|---|---|
| Feb 2, 2024 | Fine | $100K |
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Frequently Asked Questions
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Does Millcreek Manor have any deficiencies on record?
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.